Blog: Managing the Care of Health

Do you run for cure? How about running for cause.

27 July 2016

You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

Part of the problem lies with medicine itself. It is mostly about treating diseases, and since physicians do so much of the research, that’s where the bulk of the funding goes. I asked a surgeon active in breast cancer research about the proportion of funding that went to finding cause. She estimated it to be 1%. (Some physicians even refer to as “prevention” stopping Stage 1 breast cancer from advancing to Stage 2. That’s like claiming that the cause of Stage 2 cancer Is Stage 1 cancer.) True there are diseases such as Alzheimer’s that do better, but how many others are like breast cancer?

And let’s not get started on pharmaceuticals, except to note that there is no money to be made from people who are well, or at least usually a lot less money from one-shot vaccines to keep them well. So developing medications gets most of the big bucks, and siphons off a great deal of the creative talent that could be looking for causes. All around, our health care needs to be better focused on the care of health.

John Robbins has written a wonderful allegory about a cliff that people kept falling over. There thus developed a highly sophisticated effort to treat the injured, involving physicians, ambulances, and hospitals with the latest technological wizardly. Efforts were even undertaken to develop drugs to cure the injuries of the fallen. When some people suggested building a fence atop the cliff, they were ignored, or else dismissed: what did they know about health care?1

Dr Jonas Salk didn’t buy any of this. He never cured any child of polio. Instead he ensured that no child ever had to be cured. His laboratory developed a vaccine that eradicated the disease. We need more money and talent dedicated to stopping diseases, including studying the toxic effects of what we inhale, ingest, and absorb. And by the way, Dr Salk refused to patent his vaccine, with the comment that “Who owns my polio vaccine? The people. Could you patent the sun?” He could have made a great deal of money by ensuring at the outset that only the children of rich parents could get the vaccine. Instead children all over the world became protected rather quickly.

Researching cause can be quite different from researching cure. It is often more like detective work, where samples of one can be perfectly appropriate. After all, find the cause in someone and you may be on your way to finding the cause in everyone.

A 2003 poll by Hospital Doctor named Dr John Snow the greatest physician ever. Partly he earned that with a sample of 2. When an outbreak of cholera exploded in London’s Soho District in 1854, believing that the disease was water-born, even though the physicians who mattered were convinced it was air-born, he plotted the locations of the recent victims on a map. They clustered around one well, all except two, who lived miles away. Like a good detective, Dr Snow visited the home of one of them. A relative told him that she liked the water of that well and had someone fetch it for her. Her niece also liked that water, he was told, and she died too. And where did she live? There was sample Number 2. Finally Dr Snow’s colleagues listened to him. (Sewage seeping into the well—i.e., toxin—was later found to be the cause of the outbreak.). The handle of the well was removed—that was the cure! (for this well at least)—and the epidemic ended.

Some years ago, I heard about an astonishingly high incidence of certain cancers among children in Alexandria. So for this TWOG I went on the internet and found one related article, in the Journal of the Egypt Public Health Association, 2002, under the title “Patterns in the incidence of pediatric cancer in Alexandria, Egypt, from 1972 to 2001.” The article concluded that “The trends in some cancer types suggest the need of a closer examination of the underlying factors and environmental contaminants leading to the disease in children.” Yes indeed, and what a perfect place to research cause. But who is to do that: where is the constituency for cause?2 In other words, where are the Dr Snow’s when we need them now?

If you have lost a cherished member of your family to a dreaded disease, I can well understand your wish to help find a cure for it.  But cannot this emotion also be directed into helping avoid the suffering of others? So please, the next time you run for a disease, or fund a research chair, or just donate a few pennies for health care, consider cause. Invest in health.

© Henry Mintzberg 2016. HM is the Founding Director of the International Masters for Health Leadership (imhl.org) and author of the forthcoming Managing the Myths of Health Care (Berrett-Koehler, 2017). Follow this TWOG on Twitter @mintzberg141, or receive the blogs directly in your inbox by subscribing hereTo help disseminate these blogs, we now also have a Facebook page and a LinkedIn.


2 I found no follow-up study, nor any comments on that one.

 

Who can possibly manage a hospital?

6 January 2016

Great debates continue as to who should manage hospitals and other health care institutions. For example, should the head be a physician? a nurse? a professional manager? The physicians know cure, the nurses know care, the professional managers know control. But who knows all three? Is there thus good reason to reject all these candidates? I reject the question itself.

Professional managers so called, namely people who believe they are qualified to manage everything because they sat still in an MBA or MHA classroom for a couple of years, have been the target of several TWOGs here. Being educated in the abstractions of administration prepares no one for the cauldrons of practice.

Great debates continue as to who should manage hospitals and other health care institutions. For example, should the head be a physician? a nurse? a professional manager? The physicians know cure, the nurses know care, the professional managers know control. But who knows all three? Is there thus good reason to reject all these candidates? I reject the question itself.

Professional managers so called, namely people who believe they are qualified to manage everything because they sat still in an MBA or MHA classroom for a couple of years, have been the target of several TWOGs here. Being educated in the abstractions of administration prepares no one for the cauldrons of practice.

Management, unlike medicine, uses little science: hence it is not a profession. Or to put this another way, because illnesses in organizations, and prescriptions for their treatment, have hardly been specified with any reliability, management has to be practiced as a craft, rooted in experience, and an art, dependent on insights. Visceral understanding counts for a lot more than cerebral knowledge.

Well then, if not professional managers, how about physicians? Surely they have the visceral understanding of the operations, plus the status to be heard. Moreover, are hospitals not fundamentally about medicine? Yes to all of the above questions. But there is a lot more to managing health care than knowing medicine. In fact, there are reasons to believe that the practice of medicine is antithetical to the practice of management.

Physicians are trained mostly to act alone, individually and decisively. Every time one sees a patient, an explicit decision is made, even if that is to do nothing. Decision making in management is not only more ambiguous, but also more collaborative. A cartoon appeared some years ago showing several surgeons around an anesthetized patient, over the caption: “Who opens?” In management, that is a serious question! Add to this the facts that medicine tends to be interventionist, mostly about episodic cures, rather than continuous care; that it usually focuses on parts, not wholes; and that it strives to be scientific and evidence-based, and you have to worry about physicians running hospitals.

This leaves the nurses. Their practice is often more visceral, more engaging, and arguably closer to concern about the whole patient. Moreover, their jobs are ones of continuous care more than intermittent cure, plus they are inclined to engage in more teamwork. So some nurses at least should be rather more suited to managing hospitals.

Sure―but how to get the doctors to accept management by the nurses?

So the conclusion appears to be evident: no-one can possibly manage a hospital! Running even a complicated corporation must seem like child’s play compared with managing a general hospital: the strident doctors, the beleaguered nurses, the sick patients, the worried families, the demanding funders, the posturing politicians, the escalating costs, the accelerating technologies―all embedded in cases of life and death.

Yet people do manage hospitals and other health care institutions, sometimes with rather astonishing effectiveness. So beyond the evident answer to our question is the obvious answer: People, not categories, have to manage health care institutions. I have encountered physicians who were renowned as heads of hospitals. (One of Montreal’s most respected hospital directors was an obstetrician with an MBA.) Likewise have I seen some awfully impressive nurses managing hospitals―and imagine how many more there would be if given the chance.

My own preference is for people who have worked in the operations before moving into the management, whether that be in nursing, medicine, physiotherapy, or social work, etc. In fact, the wider the net is cast, the greater the chances of success.

That is not to conclude that training in management is irrelevant, only that it should follow experience on the job, and build on it. That is what we have been doing at McGill since 2006, with great success and delight, in our International Masters for Health Leadership (imhl.org), for people from all aspects of health care all over the world.

Now for the ultimate bit of administrative engineering

In a recent TWOG on managing the care of health, I discussed a number of dysfunctional forms of administrative engineering—mergers, measures, reorganizations, etc.—that are meant to fix health care where it is not broken. Some weeks ago I underwent a bypass operation in a Montreal hospital that had been administratively engineered in a particular way.

Our hospitals in Canada are mostly non-owned―they are independent trusts. But that has not necessarily stopped the provincial governments that provide most of their funding from treating them like government departments.

Last year in Quebec, the prime minister and his minister of health, both physicians, solved the problem of who should manage hospitals by deciding that no one should. They eliminated the positions of director general—head of the hospital--and indeed of most of the health care institutions in Quebec. In effect, they fired them all, and combined all these institutions into regional agglomerations, each with its own single président-directeur général (the French term for CEO).1

This is not Alice in Wonderland. In the teaching hospital where I was treated, with its 637 beds, there is no longer anyone in charge. The former directeur général was kicked upstairs—transformed into a PDG―to manage the whole agglomeration. This comprised nine (yes 9) separate institutions, across acute, community, rehabilitative, palliative, and geriatric care, etc. Think of all the money our government has saved. Think too of all the chaos that is to come.2

So I have a terrific idea. Do we really need all those government ministers? Health, Justice, Culture, Finance, Education, Agriculture, Mines, and eighteen or so more. Why don’t we just agglomerate them all, and have the prime minister run the whole works himself. Think of how much more money we could save.

© Henry Mintzberg 2016. Partly drawn from my forthcoming book Managing the Myths of Health Care.

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1 This is an unfortunately excellent example of ignoring the importance of the plural sector in society. Because of its power over funding, this government has in effect nationalized the hospitals. (The chart it drew even shows a solid line from this PDG to the minister of health, and a dotted one to the board of directors of the hospital. Dots have deep significance for bureaucrats.) As I argue in my book Rebalancing Society, professional services often attain their high levels of quality by functioning with a certain degree of independence in the plural sector, rather than the public or private ones. So much for that idea in this case.

2 Their timing might just prove to be impeccable—for the opposition parties. As I noted in my TWOG on efficiency, the cost savings of such administrative engineering show up immediately; while the negative impact on services appear later—perhaps just in time for the next election. 

 

Reframing the managing and organizing of health care—toward a system

24 December 2015

This is the third in a set of three TWOGS based on a book I am completing called Managing the Myths of Health Care. The first TWOG introduced two myths: that health care is a “system” and that it is failing. In fact it is succeeding, astonishingly (at least where it chooses to focus its attention, namely on the treatment of acute diseases rather than chronic conditions). It’s just that this is expensive, and we don’t want to pay for it. So we intervene with all kinds of administrative fixes, that were the subject of the second TWOG: measures, markets, and mergers, heroic leadership, relentless reorganizing, and making health care more like a business. Arguably, these are the causes of the perceived failures. In this TWOG I discuss some basic ways to reframe certain key practices of health care, to render it more like a system.

This is the third in a set of three TWOGS based on a book I am completing called Managing the Myths of Health Care. The first TWOG introduced two myths: that health care is a “system” and that it is failing. In fact it is succeeding, astonishingly (at least where it chooses to focus its attention, namely on the treatment of acute diseases rather than chronic conditions). It’s just that this is expensive, and we don’t want to pay for it. So we intervene with all kinds of administrative fixes, that were the subject of the second TWOG: measures, markets, and mergers, heroic leadership, relentless reorganizing, and making health care more like a business. Arguably, these are the causes of the perceived failures. In this TWOG I discuss some basic ways to reframe certain key practices of health care, to render it more like a system.

Clearly we need administrative engineering to keep the lid on the costs of health care. But that does not mean, to quote from a flamboyant article in the Harvard Business Review, that hospitals need to be seen as “focused factories”, doctors as “industry players”, and patients as “customers” and consumers” who carry out “one-stop shopping” for their services.

Beyond being a patient, I am a person. Beyond being part of some population, we are members of communities. Practiced properly, health care is not a business at all, but a calling. Can anyone possibly believe that most physicians, nurses, and other professionals would work as conscientiously as they do, in the face of so much pressure and frustration, in order to maximize the  “value” of some shareholders they never met?

There is thus a compelling need to proceed differently in health care, with scalpels instead of axes, out of the administrative offices and into the operating rooms, of all kinds. What looks good on paper can wreak havoc in practice because administrative prescriptions are often simple and reality is often complex. So ways have to be found to combine the efforts of dedicated professionals with those of engaged managers.

In the final section of my book Managing the Myths of Health Care, I discuss reframing across various key aspects of health care. Those concerning managing and organizing are discussed here. We do not have the space to get into three others: Reframing Scale—to make the default position human scale rather than economic scale; Reframing Ownership—to recognize the key role that common ownership has to play in this field beside public and private ownership; and Reframing Strategy—as venturing, not planning (which is touched upon here). I may discuss these in later TWOGs.

Reframing Management: as distributed beyond the “top”

Most everywhere, an essential problem in health care lies in forcing detached administrative solutions on to practices that require informed and nuanced judgments. In a 1994 article on health care reform, Donald Berwick put it: “Only those who deliver care can, in the end, change care…. The outsider can judge care; but only the insider can improve it.” Clinicians should, therefore, “stop feeling battered” by the reforms and begin to do something about the problems. Bear in mind that it was clinicians who developed day surgeries: one of the great advances of health care in recent times, that both cut costs and improved qualities dramatically.

In fact, eliminating the word “outsider”, as well as the vocabulary of “top” and “middle”, would also help, by challenging the artificial gaps between levels of administrative authority as well as those of professional status. Everyone who works in this field contributes and therefore deserves the full respect of everyone else, so long as they return that respect.

There are three ways to close the artificial gaps between administration and operations: One is to bring “down” this “top” by wooing those people concerned with administration―managers, administrative engineers, government officials, and so on―off their hierarchical pedestals and into more direct contact with the operations. A second is to bring the base “up” by involving the providers of the services in the administrative practices (without necessarily having to become managers). But most important may be eliminating the formal levels between administrations and operations—for example by favoring smaller institutions and regions in the first place.

Concerned and committed people in all kinds of unexpected places can improve the practice of health care, much as so many people are changing Wikipedia every day. (Think of this as open source strategizing.) A policeman in receipt of dialysis treatment helped reorganize the scheduling for everyone’s benefit. “Let a thousand flowers bloom” could thus be the motto for driving effective changes in health care.

Reframing Organization: as collaboration transcending competition

There is no doubt that we are all competitive beings, from which can spring good and bad. But we are also cooperative beings, from which can spring a lot more good, especially in health care, where we already have too much competition. In the name of that competition, health care suffers from individualization: every recipient, every provider, every institution for him, her, or itself. So enough of professionals grinding in their own mills, apart from managers who try to remote control them, let alone apart from each other who believe they can coordinate everything on automatic pilot. There are no management problems in this field, separate from medical problems or nursing problems or prevention problems, etc. There are only health care problems. 

Reframing the Practice of Managing: as caring before curing1

Instead of leaders who don’t manage, health care needs managers who lead. Such managers are part and parcel of their institutional community; they do not sit “on top” of it.

In response to a newspaper commentary I published about heroic leadership, a retired manager of nursing wrote to me about her experiences with people “not skilled in understanding the work of front-line staff… [they] managed from a meeting, from their offices, or from their home computer”:

In health care today, the vertical monopoly structure is leaving the front-line point-of-care team questioning where is the support, where is the leadership, where is the inspiration, where are the coaches, who really cares? I do not believe there is a shortage of staff; there is a lack of retention of staff. The idealistic, intelligent, youth are not satisfied with mediocre leadership and turn to other professions to have their dreams fulfilled.2

Health care institutions—and businesses too these days—need something quite different: managing as convincing more than controlling, demonstrating more than directing, inspiring more than empowering, above all managers who engage themselves in order to engage others. Put differently, in health care managing itself should be about dedicated, continuous, holistic, and pre-emptive care more than interventionist, episodic, narrow, and radical cures.

How to get to this? Managers can start by purging their organizations of the corporate vocabulary—“CEO” and all the rest. On the ground, they can experience people beyond patients, providers beyond professionals, communities beyond populations. And by the same token, the providers can be reaching out sideways, to communicate with each other more effectively for the sake of continuous care.

As discussed in the TWOG of the week before last, a cow is a system: its parts function harmoniously. Why can’t health care work like that?

© Henry Mintzberg 2015, Have a look at our International Masters for Health Leadership (imhl.org), where mid-career people from all aspects of health care the world over get together for five 11 day modules to consider all this and much more.


1 See my book Managing (Mintzberg, 2009), which discusses a day in the lives of 29 managers, including seven in health care―from a head of the NHS in England to a head nurse of a surgical ward (with full descriptions on www.mintzberg-managing.com). Simply Managing (2014) is a shorter version of this book.

2 Barbara Carroll of Kelowna, British Columbia, in personal correspondence, 25 March 2009, used with permission